Situation
In the Netherlands, the deductible is an essential part of the healthcare system, designed to regulate healthcare usage and keep healthcare costs manageable. The current deductible is €385 per year, but there are growing concerns about the accessibility of care for vulnerable groups such as chronic healthcare users and care avoiders. These concerns have led to political debates and policy proposals to revise the deductible. The Dutch government is set to adjust the deductible in 2027, spreading the cost over multiple treatments, €50 per treatment with an annual maximum of €165. While these adjustments are intended to increase access to care, little is yet known about the broader social impact of such changes to the deductible.

Complication (Question)
The central question of this thesis is: “What are the social costs and benefits of the policy change in the Dutch deductible to €50 per treatment with an annual maximum of €165, compared to the current system, for the entire Dutch society over the period 2027-2070?”

Approach
To answer this question, a Social Cost-Benefit Analysis (SCBA) was conducted to evaluate the social impact of four policy options: elimination of the deductible, reduction to €50, reduction to €165, and the Spread scenario. The SCBA looked at both quantified and monetized impacts, including the benefits of accessibility through perceived cheaper care, increased costs of nominal premiums and income-dependent contributions through changes in healthcare usage, costs, and health benefits. The analysis period was from 2027 to 2070 and took into account uncertainty factors such as population growth and price elasticity of health care demand. Sensitivity and uncertainty analyses were conducted to evaluate the robustness of the results, and critical assessments were made of the assumptions underlying the model.

Results
The analysis showed that all four scenarios result in a negative Net Present Value (NPV), indicating that costs exceed benefits over the entire period of analysis. The Spread scenario resulted in a total NPV of -€194 billion, with an average annual NPV of -€4.41 billion with extremes values
-€4.92 billion and -€2.56 billion. These results suggest that the social costs, mainly caused by higher nominal premiums and income-related contributions, significantly exceed the expected benefits, such as reduced spending on deductibles and health benefits from improved access to care.

In addition, the results show that the intended financial threshold of the Spread scenario may not be effective in reducing healthcare usage. The analysis indicates that total costs for healthcare users under this scenario are often lower than under the current situation, even after multiple treatments. This implies that the lower cost per treatment may actually encourage rather than inhibit healthcare usage, leading to higher healthcare usage, longer waiting times for care, quality reduction in care, and higher costs to society.

At the individual level, we are talking about an average annual NPV of €275 per person. But this includes an increase in nominal premium and income dependent contribution of €452.90 plus the cost of the deductible. This will increase nominal premium more than the deductible will decrease. Society's solidarity will be greatly called upon, because the difference between payments for healthcare users and non-healthcare users will be significantly reduced, while the cost of the nominal premium will increase by 26%.

Next Steps
The study contained several assumptions that require further research to reduce uncertainties. It is recommended that follow-up research be conducted on detailed demographic analyses to better understand societal responses to policy. Furthermore, it is important to identify the long-term effects of early disease interventions to better estimate future care needs. In addition, it is crucial to reconsider the current policy proposal and conduct extensive research on its potential effects to ensure that policy goals are achieved without undermining solidarity.

The findings of this thesis contribute to the broader debate on the future of the Dutch healthcare system by emphasizing that policy choices around the deductible should not only be financially feasible, but also fairly and sustainably aligned with the fundamental values of solidarity and accessibility in healthcare.

The reimbursement scheme in geriatric rehabilitation (GR) contains stepwise tariffs depending on both the length of stay and treatment intensity: after a pre-determined number of inpatient days or treatment hours, the total reimbursement jumps to a higher level and then stays constant until the next threshold is reached. These discontinuous reimbursements may distort physicians’ behaviour in a way that is detrimental to the efficiency of care provision. This thesis examines whether these behavioural distortions are present regarding GR and, if so, which factors are associated with stronger distortions on a GR provider level. For this goal, GR claims data from health insurer CZ covering the years 2017–2023 are used. Furthermore, this thesis qualitatively assesses the possible consequences of the proposed changes in the payment system of GR, including the abolition of the current stepwise tariffs, using insights from GR claims data and economic theory.

Background: A shift in the organisation of oncology care towards collaboration between hospitals in oncology networks (CCNs) is observed to allow high-quality, accessible, and affordable care in the future. The collaborating hospitals align their care processes and design a joined regional care pathway (RCP) to standardise and structure their care. Within an RCP the patient is transferred between hospitals in the CCN, often for specialised and complex care like surgery.

Problem statement: The various disciplines and institutions involved in care delivery ask for coordination of care, clear agreements, and proper handovers of tasks. Inter-organisational collaborations within a CCN introduce new challenges (e.g. in information exchange) regarding coordination compared to multidisciplinary intra-hospital collaboration, because organisational and geographic boundaries are crossed. Unfortunately, little is known about how coordination between collaborating hospitals in a regional oncology care pathway can or should be achieved. Therefore, this thesis aims to contribute by developing a framework guiding improvements in coordination for RCPs.

Methods: A mixed-method approach was used which included a literature search and semi-structured interviews with healthcare professionals in oncology networks, policymakers, and patients. A selected conceptual framework of care coordination was adapted based on literature and each aspect within the framework was defined. Additionally, evaluation measures and improvement actions for each aspect were identified. The interviews were used to elaborate the findings from literature and incorporate the right context for RCPs. Moreover, the interviews gave insights into the experienced challenges and best practices. Lastly, the developed framework was applied in a case study.

Results: The framework for Care Coordination in Chronic and Complex Disease Management was opted as an initial conceptual framework and was extended by three additional aspects identified by other studies. The framework categorises the aspects of care coordination in domains creating an overview of the relation of each aspect in the coordination processes. The interviews resulted in two extensions of the original framework: 1) Alignment of resources and processes besides cultural alignment; and 2) leadership/coordination at the network level besides the boundary-spanning role of the case manager at the patient level. All aspects of the framework fit the RCP context, although some overlap between the aspects was identified.

Conclusion: The framework supports hospitals in improving coordination between hospitals within the RCP by offering an overview of aspects, evaluation measures and improvement possibilities. Information exchange, communication, and clear RCP protocols with defined roles and responsibilities turn out to be important aspects that facilitate coordination. These should be supported by boundary spanning actions and emergent conditions, like personal relationships and trust. Especially organising digital exchange of patient information is important for CCNs, but is still challenging to establish. A well-designed monitoring system including reminders and alerts will support coordination. However, regional dashboard development is challenged by non-structured data and differences in data structures between the hospitals. To further scale up initiatives for larger challenges and more resourceful improvement initiatives (e.g. digital exchange of EMR data), close collaboration within and between CCNs, and exchange of knowledge, tools, and best practices should be established.